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The aim of this essay is tounderstand language barriers and miscommunication that may occur in ahealthcare setting between patients and healthcare practitioners, especiallywhere at least one of the speakers is using a second (weaker) language.It is important thathealthcare professionals understand that the key to good holistic care iscommunication, particularly since patients require information and reassuranceregarding their care.  Communication is something we do every day, it isthe process of receiving and sending messages between two or more people. It is not just talking to each other that defines communication, but it is howwe respond to each other in many different ways (Langs,1983).  There aremany varied examples of communication, such as, reading, singing, talking,writing and body language.

  In order for communication to be effective, itfirst needs to be established as well as maintained. In terms of a healthcaresetting, this can be done during an assessment when a patient arrives at the practice.Stuart and Sundeen (1995), state that communication can either create barriersand this is the case as it is argued that  communication barriers canprevent effective and appropriate care being provided to patients however theyalso debate that it may aid in the development of a therapeutic relationship.In some instances, bysimply observing an individual, many problems which can hinder communicationare able to be discovered.  If the patient has any visual impairments,physical disability or illness, observation can be used to determine whichlanguage is being used or the way the patient is able to communicate with thehealthcare professional, as any of the issues stated could control the way theindividual is able to communicate.Within our generalpractices, individuals of all nationalities deserve the best carepossible.  However, language barriers and the misunderstanding betweenindividuals it proposes puts a restraint on patient care. Miscommunication inany instance could lead to potential issues however within the health caresector miscommunication may result in lower patient satisfaction scores,illnesses or could even be life-threatening when streaks of communication arecrossed.

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Hence, one of the most important tools that we use to provideoutstanding patient care as well as improve patient satisfaction iscommunication. Around 9 out of 100individuals have limited English proficiency.  It is believed that thereare approximately 6000 languages spoken in the world.  When wanderingaround in modern Britain, the South East to be precise, most of these languagesare apparent. More so when you walk into any large NHS Trust in the city wereside in.  There are many challenges that the multicultural andmultilingual world brings. The question is, if we struggle to make sense ofeach other’s worlds, how do we work together as well as support each other.

Many people from differentcultures and backgrounds walk through the doors of general practices in Londonevery day.  I am currently training in a busy North London practice, andwhilst on placement I observed many encounters where language barriers becamean obstacle.  The English language barrier in comparison to other nativelanguages has made it difficult for healthcare professionals to perform theirjob to their fullest potential. This subsequently leads to unnecessary mistakesin the Practice of Medicine due to miscommunications because of the differencesin language. But how can we optimize thecare and information they receive?  Language and culturaldifferences are the main communication barriers in which I have observed withinGeneral Practices, where patients and healthcare professionals not speaking thesame language is something that has now become an occurrence.

This is despiteeffective communication with patients in primary care being an essential partof the planning and delivery of appropriate high-quality and safe patient care.Overtime there has been anincrease in not only the number of migrant patients however also in the staffwho are foreign-trained. Consequently, the likelihood of communication errorsrises as English may be a second language in which some still aren’t proficientin and when either the healthcare practitioner or patient attempt tocommunicate with each other on this basis, there is likely to bemisinterpretations or confusion in what they are trying to put across. Inaddition, methodically there is limited research into this that addresses thisissue.There is a rise in numberof foreign-trained members of staff and patients, which means that errors incommunication between patients and healthcare staff when a second language isspoken between one or both are increasingly likely. Hiring an interpreter whocan speak the patient’s language as well as aid the healthcare professional inmaking the appropriate choices towards making the individual better, can helpprevent fatal mistakes from occurring.

  As simple as this solution maysound, many general practices have no access to an interpreter and healthcareprofessionals have little training in dealing with people of a differentlanguage. On the other hand, a problem which arises with the use ofinterpreters is that patients tend to have a concern with indirectcommunication with the health professional. Vital information that couldsignificantly affect the diagnosis may be omitted as the patient does not feelcomfortable disclosing this with the interpreter.

Even with an interpreter,there is still a large chance that there could be misinformation between thehealthcare professional and patient, missing key information that couldendanger the life of the patient. The useof a non-professional interpreter, such as friends, bilingual member of staffor even a family member can erupt a few ethical issues, the issue with using untrainedinterpreters for issues relating to health or care discussions can usuallyraise legal and professional challenges for nurses, as well as patientdisclosure implications The NMC (2008) states that patients are entitled totheir confidentiality and this must be respected by the nurse.  HealthScotland (2008) advises that it is not recommended for children to be substitutedas interpreters, as they may become distressed, may lack the understanding andmaturity of what is being communicated and also the patient be may be reluctantto disclose certain information to a younger person. Nurses cannot be entirelysure if the information that is being translated to the patient is correct (Black,2008). (NMC, 2008) requires nurses to disclose health and treatment informationif it has been requested.

 Forpatients suffering from anxiety related illnesses there will be miscommunicationfrom the initial stage. In result of this psychological stress from the patientwill become apparent as well as medical discrepancies possibly displayed fromthe healthcare professional. In the scenario of a patient and a healthcareprofessional are communicating in different languages, it is important thatpatients fully take in the advice the practitioner in a medical context.

Nevertheless,because there is a mismatch in languages, patients are more likely to fail in adheringto the professional’s directions and in some cases saving their life. This iswhy it’s essential that there is a clear understanding between the doctor andpatient.In the instancethat the patient’s fluent language is conflicting with wider community and thepractitioner, it will distort the health related risks from the patient to thepractioner and prevents resolutions to be accurately and appropriatelyconveyed. In a sector where a vast number of cultural groups is involved,specific feelings including distress and pain can be portrayed differently, whichcomplicate matters even further.  Eventhough in some cases, glimpses of the English language is shown; Metaphors, culturally-specificterms or expressions can be challenging to navigate.  Furthermore, when interpreters areunavailable and clinicians lack the cultural and linguistic skills required. Patientshave no choice but to rely on bilingual medically inexperienced relatives ornon-medical staff.

This heightens the chance of worsening health outcomes andthe quality of care for the minority communities.Within alanguage-discrepant medical communication setting, there are at least threetheoretical approaches to understanding why communication problems arise.  The first approach is discussed by Segalowitzand Kehayia, which is called a psycholinguistic approach, this approach focuseson the way in which the speaker directs the attention of focus of the otherindividual to key elements of their message, and this is done by using syntacticand semantic features of the language to appropriately package the message.Thesecond theoretical approach examines the conversational dynamics ofpatient-doctor interactions.  The powerrelation differences between patient and doctor, also how the use of languageboth serves as a tool for manipulates them and reflects these relationships, iswhat this approach focuses on.  Not muchis known in regards to the social dynamics in which operates healthcarelanguage-discrepant.Theframework of Communication Accommodation Theory (CAT) is the third theoreticalapproach.

  This approach has particularrelevance for the comparison of language-congruent and language-discrepantcommunication.  Firstly, The CommunicationAccommodation Theory puts forward that speakers attempt to converge theirmanner of speaking in order to achieve significant social goals aroundaccomplishing social identity, approval etc. secondly the efficiency ofcommunication is reflected by the extent in which speakers converge, thirdlyconvergence is viewed as both normative and positive.  And finally in manner of speaking, divergenceis normally perceived negatively and reflects a specific intention.

CommunicationAccommodation Theory (CAT) is also a convenient framework which is used to examinethe dynamics of patient-practitioner communication.   An inability in some cases to achieveconvergence (i.e.

appearing similar in speech) can usually affect the qualityof the working relationship between the patient and the practitioner but alsohow the speakers perceive each other. The main goal is identifying the specific impacts that languagediscrepancy has as well as what the patient-practitioner communicationconsequences are.It isstated that communication is not simply a facilitator or an adjunct of healthcare, communication is also a core component according to Schyve (2007).  It has long been recognized that goodcommunication between patients and providers is important. Medicines mostessential technology is language, which is the principle instrument forconducting its work (Jackson, 1998).

  Clark (1983) observed that the work of a veterinarian and a physician (orother health providers) would almost be identical.Therehas been reviews in literature in regards to patient-provider communication,which indicates that as well as the effects on the satisfaction of patients,there is a correlation between specific health outcomes (for example, recoveryfrom symptoms, pain, physiological measure of blood pressure am blood glucaose)(Kaplan et al, 1989; Williams et al, 1998; Teutch, 2003; Stewart, 1995; Stewartet al, 1999; stewart et al, 2000) and also the quality of communication.  Improved health outcomes have been linked tothree basic communication processes.  Thefirst process which has been identified is improved health outcomes, the secondprocess is the control of dialogue by the patient, and finally the last processis the established rapport ( Kaplan et al, 1989).  All of these processes are put at risk in encountersof language discordant.Patientswho do not speak the same language as their provider are put in the same risk categoryof poor communication as all other patients.

 Nethertheless, other additional risks are presented with languagebarrier.  As simple as it may seem toimprove the provider’s general communication skills it is not enough to addressthe risk that are encounted by patients who do not speak the samelanguage.  An increased likelihood ofmalpractice complains and claims, risk to providers are all caused by poorcommunication (Domino et al, 2014; Lussier and Richard, 2005).  There are many literature focusing oncommunication between medical personnel, including patient handovers, but notmuch on the safety of patient literature relating to communication has focusedon miscommunication between patient and provider.   Eventhough these are different concepts, equally, there have been issues ofcultural responsiveness or competence and linguistic, which have often beenconflated.

  Between health care providersand patients, there have been many different approaches addressing culturaldifferences.  These approaches include, culturalcompetence, cultural proficiency, cultural appropriateness, congruence,cultural sensitivity and cultural awareness. All these approaches are based on different assumptions.  Particularly cultural competence, which haspotential pitfalls and has been identified with several authors suggesting culturalsafety (Coup, 1996) or cultural humility (Tervelon&Murray-Garcia, 1998) asalternatives.  In aculturally diverse society, the proposed preferred strategy for quality care ispatient centred care (Epner & Baile, 2012).

 It has been concluded that if the ethnic and racial disparities are tobe addressed, language barrier will be the target.  This is not because they are the mostdocumented source of disparities but because for a truly patient-centred care,communication is a basic requirement (Saha & Fernabdez, 2007).  According to research that has been focusedon mainly experiences with care by patients and communities, it has beenidentified that within the minority communities themselves, language barriers isalso a priority (Stevens, 1993; Ngwakongnwi et al, 2012).Fewer visitsfor non-urgent medial problems and lower frequency of general check-ups areassociated with a language barrier (Derose et al., 2000; Pearson et al. 2008).

  Fiscella et al (2002) also states that healthcare visits are significantly more likely to be fewer for individuals withlimited English proficiency.  Studies conductedby Ayanian et al (2005) found that patients with language barriers are lesscontent with communication from doctors, staff helpfulness as well as givinglow assessment of psychosocial care.  Individualswho experience problems in regards to their care have been identified to be theones who experience language barriers with their providers according tostudies.When languagebarrier is present, a review of literature has revealed that there isconsistently a significant difference in compliance and understanding.  Lack of understanding of what has been saidis usually the reason why patients are not satisfied.  This results in lower adherence to theprescribed treatment.  In the medicalencounter, poor communication usually results to inaccurate and incomplete history,misinformation for treatment plans, misdiagnosis and the patient usuallylacking understanding of his prescribed treatment and condition.

Languagebarriers can lead to poorer controlling of disease outcomes and management,even if the diagnosis of a condition is correct.  For example, in the case of diet and physicalactivity there is less of a chance of the patient being counselled (Eamanond etal, 2009).  There are only a small numberof patients who lack fluency in the English language that have reported receivingcounselling on health and lifestyle or for a patient suffering fromhypotension, heart disease or diabetes, getting the advice to have their bloodpressure checked on a regular basis (Kenik et al, 2014).In thearea of reproductive health and sexuality, language barriers present additionalchallenges.  According to Coronado et al(2007), counselling and testing for sexually transmitted diseases (STI) andhuman immunodeficiency virus (HIV) may be less likely received by limited Englishproficient individuals.

  A particularconcern in regards to the fear of loss of confidentiality leads to worrieswhich may be stigmatizing or embarrassing.Anotherparticular area in which language barrier has great impact on is pain management.  Higher levels of pain control, greater helpfulnessfrom their provider to treat their pain and timely pain treatment were reportedby obstetrical patients who always received interpreters, in comparison to tothose who do not always receive interpreters, this has been identified by the studyby Jimenez et al (2014).

  Further studieswhich have investigated ethnic/racial differences in terms of management ofpain, has also identified that language also contributes to the control ofpain.  An example of this is Cleeland etal (1997), who found that compared to 50% of non-minority patients, only 35% ofminority patients with cancer, received recommended guideline analgesicprescriptions.Theimpact of language barriers on management of chronic disease management hasbeen the main focus of many studies. But the area that has received the mostattention and a particular concern at this current time is the management ofasthma and diabetes.  Due to limitedfluency in the English language, risk factors have been noted in the managementof diabetes.  These include fewer footchecks, less likelihood of a self-monitoring blood glucose being performed,less likelihood of receiving education on diabetes and also less wellcontrolled symptoms of diabetes (Eamaranond et al, 2009).Within theageing population, it has been identified that increasing challenges around languageaccess are being reported by health providers, states Koehn (2009).  Bouchard et al (2009) also states thatconcerns have been expressed by elderly minority language speakers aroundcommunication.

  It has been observed thatmany clients who have had a significantly high level of English proficiency throughouttheir working lives, as a result of the ageing process tend to loose thissecond language ability, even when dementia is absent (Clyne, 2011).  When under stress, the first language of manyolder patients is more likely to return. In the case where a patient is suffering from a cognitive impairment,this attrition of second language may be more acute (Kieizer, 2011).

  According to Murtagh (2011), there are noclear reasons for this attrition.Languagebarrier also affects the quality of end of life care (Granek et al, 2013).  In comparison to patients with family membersreceiving information who are English proficient, those with non English familymembers are at a higher risk of fewer information regarding the illness oftheir loved ones (Thornton et al, 2009).Criticalstandards in the delivery of ethical, quality care are ensuring informedconsent is obtained aswell as maintaining patient confidentiality.  Informed comsent is not achieved for patientswith limited English proficiency accordinf to evidence.

Anothercritical area that language barrier affects is medication use.  It has been identified by many studies of thehigh rise in errors in medication amongst individuals who face languagebarriers.  Studies have shown thatincreased risk of complications along with less control of symptoms areapparent when language barrier is present (Dilworth et al, 2009).  Barton et al (2013) found that it is more likelyfor English proficient individuals to report issues understanding the purposeand category of medication than limited English proficient individuals.

  There is a lack in knowledge of the frequencyand dosage of the drug.A long term solution to this issue will befor our healthcare system to invest and provide a consistent dominantinterpreter service, for providers as well as patients, that will be availableat all times to facilitate, offering optimal communication between providersand patients, as this will improve patient safety and satisfaction.  However, in the meantime, an effort must beput forth to help these individuals.

Short term solutions such as using visualmethods.  For example, showing pictures, usingsimple and plain language, avoiding medical jargons, photographs or pictographsdemonstrating techniques and medication use.  According to RCN (2006) andDivi et al (2007), difficulties in communication which is encounted between healthcareprofessionals and patients can cause ineffective treatment plans and misdiagnosis.  It is a requirement for nurses to meet communicationand language barriers and also to take the necessary actions to meet the needsof ethnic minority patients, this ensures that the information that has beendelivered is understood (NMC, 2008).

 This is of great importance as it allows understanding of the views ofpatients, expectation of the delivery of care as well as their thoughts, thiswill then enable the nurse to meet their needs.Effectivecommunication takes into account of, cultural differences, language and alsohealth literacy, which are all seen as the way to safe health care.  The most frequent root cause of seriousevents that occurs in the healthcare setting is due to communication.  Many studies have identified that limited Englishproficiency patients suffer serious adverse outcomes than English speakingpatients.  In order for health careprofessionals to achieve high quality and safe care, cultural, linguistic andhealth literacy barriers to patient needs to be addressed immediately.There are many impacts that effectivecommunication can have on the quality of care in which nurses provide topatients.  In the case where limited orno English is present, legal, professional and ethical challenges and issuesare raised, in meeting the communication needs of these patients.

  But despite this, implementing and planning waysand strategies to overcome language barriers, nurses can have many positiveeffects on patients in this particular group.Our jobas healthcare professionals are to mitigate communication issues and offeringthe best care possible to our diverse patient population.  There needs to be an awareness of the many difficultiespatients with limited English proficiency have to face.

  We must create an environment that iswelcoming, and encourage these individuals to seek the care that they need,even if there is a language barrier.   

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